Cancer of the cervix uteri prevention

Screening and HPV Vaccination

dr. Marihot Pasaribu, Mkes, SpOG, Subsp.Onk

  Cervical cancer is the fourth most common cancer among women globally, with an
estimated 604 000 new cases and 342 000 deaths in 2020.

• About 90%
of the new cases and deaths worldwide in 2020 occurred in low-
and middle-income countries.

• Two human papillomavirus (HPV) types (16 and 18) are responsible for nearly 50% of high
grade cervical pre-cancers

• HPV is mainly transmitted through sexual contact and most people are infected
with HPV shortly after the onset of sexual activity. More than 90% of them clear the

Key facts
infection eventually.

• Women living with HIV are 6 times more likely to develop cervical cancer compared to
women without HIV.

• Vaccination against HPV and screening and treatment of pre-cancer lesions is a cost-
effective way to prevent cervical cancer.
• Cervical cancer can be cured if diagnosed at an early stage and treated promptly.
• Comprehensive cervical cancer control includes primary prevention (vaccination against

HPV), secondary prevention (screening and treatment of pre-cancerous lesions),

tertiary prevention (diagnosis and treatment of invasive cervical cancer) and
palliative care.
  Cervical cancer is the fourth most common cancer in women
worldwide.
 Cervical cancer is a disease that develops quite slowly and
begins with a precancerous condition known as CIN.

Introduction  CIN is easily detected in a routine Pap smear and is

completely treatable.
 Cervical cancer is a malignant tumour deriving from cells of
the cervix.

Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis VOLUME 8, ISSUE 2, PE191-E203, FEBRUARY 01, 2020
  Approximately 570 000 cases of cervical cancer and 311 000
deaths from the disease occurred in 2018.
 The estimated age-standardized incidence of cervical cancer
was 13·1 per 100 000 women globally and varied widely
Epidemiology among countries, with rates ranging from less than 2 to 75 per
100000 women.
 Cervical cancer was the leading cause of cancer-related death
in women in eastern, western, middle, and southern Africa.
  Cancer that starts in the
cervix – the lower part of
the uterus (womb) that
connects to the vagina
(birth canal)

• Two cell types: squamous

and glandular

• Cervical cancer tends to

occur where the two cell
types meet (called the
What is cervical transformation zone).

cancer?
  A woman has a higher-than-average risk
of developing cervical if :
 Has had multiple sexual partners.
Sexual History  Began having sexual relations before
the age of 18.
 Has a partner who has had sexual
contact with a woman with cervical
cancer.
  Smoking
 Weakened immune system
 Several pregnancies
Risk Factors  Giving birth at a very young age
 Long-term use of the contraceptive pill
 Family history
  Staging of cervical cancer is based principally on clinical
examination.
 Pelvic examination (speculum,bimanual and rectal
examination) should be done under anesthesia.
 The routine supplementary investigations include X-ray chest,
intravenous pyelography, cystoscopy and proctoscopy.
Staging  CT scan, MRI, Positron Emission Tomography (PET),
Lymphangiography can detect involvement of the pelvic or
periaortic lymph nodes and parametrium.
 MRI is helpful to detect parametrial extension and to define the
tumor volume.
Revised FIGO staging for carcinoma of the cervix
uteri

Int J Gynaecol Obstet. 2019 Apr;145(1):129-135.

Revised FIGO staging for carcinoma of the cervix
uteri

Int J Gynaecol Obstet. 2019 Apr;145(1):129-135.

Sign and Symptom

Nyeri pinggang bagian

belakang (akibat hidronefrosis)
Bengkak pada Penurunan berat
tungkai badan

Perdarahan dari kemaluan

yang abnormal
Keputihan yang
berbau busuk
Nyeri daerah panggul atau nyeri saat
Nyeri saat buang air Susah buang air berhubungan seksual
kecil besar
  Primary surgery
Management of  Primary radiotherapy
Carcinoma  Chemotherapy
Cervix
 Combination therapy
Complication of
surgery
Radiotherapy
 External pelvic radiation
 Internal pelvic radiation
Complication
 What can be done

Get Vaccination
& screened
This is a well-proven way to prevent cervical cancer and find pre-cancers.
If a pre-cancer is found it can be treated, stopping cervical cancer before it really
starts.
 Natural history of high-risk
cervical
human papillomavirus (HPV)
infection
Global Strategy
to accelerate the
elimination of
cervical cancer
 The life-course
approach for cervical
cancer prevention and
control
HPV-DNA testing detects high-
risk strains of HPV, which cause
almost all cervical cancers.
HPV mRNA detects HPV
infections leading to cellular
transformation.
 All contain VLPs
The first vaccine licensed in HPV
2006.
• All administered
before the onset of
• Currently 6 prophylactic HPV vaccines
sexual activity
HPV Vaccines • Bivalent HPV vaccines
• Cervarix • Females aged 9
• Cecolin
• Walrinvax
years or older up
• Quadrivalent HPV vaccines : to 26 or 45 years
• Gardasil of age
• Cervavax
• Nonavalent HPV vaccine
• Some licensed for
• Gardasil9 use in males
*nonavalent vaccine
 Dose Multidose Single dose
schedules schedules schedule

Doses

(i) Multidose schedules

 HPV vaccines were first licensed and marketed using a 3-dose vaccination schedule.
However, a 2-dose schedule for young adolescents was subsequently approved, based on
immunogenicity and effectiveness data

(ii) Single dose schedule

 Data from immunogenicity trials, post-hoc analyses of efficacy trials, and post-licensure
observational studies among females have demonstrated that a single dose of HPV vaccine is
sufficient to elicit an immune response that provides similar protection as a multidose
regimen against initial and persistent HPV infection
 HPV vaccines
WHO recommends schedule
WHO (December 2022)
recommends • A one or two-dose schedule for girls aged 9-14
schedule • A one or two-dose schedule for girls and women
aged 15-20
• Two doses with a 6-month interval for
women older than 21
Strengths :
• The assay result
Screening Methods
is a definite end-
point.
Limitations :
• Requires
Proprietary
supplies and
equipment unit
cost is often high.
• the result will not
Strengths :
be immediately • Simple and inexpensive.
available • The results immediately
• Can be performed by a wide
personnel
• Requirements are minimal.
• A positive result can be
followed by an offer of
immediate treatment
Limitations :
• Providers need initial
supervision and continuing
Education
• The end point is Subjective
• Not appropriate for many
postmenopausal women.
Strengths :
• proven effectiveness to decrease
cervical Cancer
• widely accepted
• Quality control and quality
assurance are well established.
Limitations :
• require clinical and laboratory
quality control and quality
assurance.
• Interpretation is subjective.
• Results are not immediately
available
Strengths :
• Samples can also be used for
molecular testing (such as for
HPV DNA).
• Quality control and quality
assurance are well Established
.Limitations :
• More expensive than for
conventional cytology
 ‘screen-and- “screen, triage
treat and treat
Screen and approach” approach”
Treat based on a positive primary
based on a positive primary screening test
followed by a positive second test (a
screening test only. “triage” test), with or without
histologically confirmed diagnosis
ALGORITHM 1.
PRIMARY VIA
SCREENING
(SCREEN-AND
TREAT
APPROACH)
 ALGORITHM 2.
PRIMARY HPV DNA
TEST SCREENING
(SCREEN-AND-TREAT
APPROACH)
 ALGORITHM 3.
PRIMARY
CYTOLOGY
SCREENING AND
COLPOSCOPY
TRIAGE
(SCREEN, TRIAGE
AND TREAT
APPROACH)
 ALGORITHM 4. HPV
DNA SCREENING AND
HPV16/18 TRIAGE
(SCREEN, TRIAGE AND
TREAT APPROACH)
 ALGORITHM 5.
PRIMARY HPV DNA
SCREENING AND VIA
TRIAGE
(SCREEN, TRIAGE AND
TREAT APPROACH)
Single-Visit approach of cervical cancer
screening
  Modality commonly two types
 Destruction
 Cryotherapy:
Treatment of  Thermal ablation
precancerous  Excision
lesions  Loop electrosurgical excision procedure
(LEEP):.
 Cold knife conization:
 Hysterectomy
Treatment of
precancerous
lesions
Treatment of
precancerous
lesions
 a) Imaging and pathology can be used,
where available, to supplement clinical
findings with respect to tumor size and
extent, in all stages. Pathological
findings supersede imaging and clinical
findings.

b) The involvement of vascular/lymphatic

spaces should not change the staging.
The lateral extent of the lesion is no
longer considered.

c) Isolated tumor cells do not change the

stage but their presence should be

Cancer of the
recorded.

d) Adding notation of r (imaging) and p

(pathology) to indicate the findings that

cervix uteri
are used to allocate the case to Stage
IIIC. For example, if imaging indicates
pelvic lymph node metastasis, the stage
allocation would be Stage IIIC1r; if

staging
confirmed by pathological findings, it
would be Stage IIIC1p. The type of
imaging modality or pathology
technique used should always be
documented. When in doubt, the lower
staging should be assigned.
 • HPV vaccination : Girls and boys, as appropriate
PRIMARY • Health information and warnings about tobacco use*
PREVENTION • Sexuality education tailored to age and culture
• Condom promotion/provision for those engaged in sexual activity
Girls 9–13 y.o • Male circumcision

Take Home SECONDARY

A
PREVENTION
• “Screen and treat” with low-cost technology, e.g. VIA followed by
cryotherapy
• HPV testing for high-risk HPV types (i.e. types 16 and 18, and also types

Messages Women >30 y.o

31,33,45 and 58)

TERTIARY • Treatment of invasive cancer at any age

PREVENTION • Ablative surgery

• Radiotherapy, Chemotherapy, Palliative care
Women >30 y.o
 PT Bio Farma (Persero) turut mengembangkan kit diagnostik
untuk deteksi HPV DNA.
 Kit diagnostik yang kini telah dipasarkan dengan nama
CerviScan
 Mendeteksi DNA dari virus HPV dengan pemeriksaan sampel
pada apusan atau swab dari lendir serviks (leher rahim) maupun
sampel pada urine
  Single-visit approach of cervical cancer screening: See and Treat in Indonesia. JNI
Vet*,1, JL Kooijman1, FC Henderson1, FM Aziz3, G Purwoto3, H Susanto6, IGD
Surya7, S Budiningsih4, S Cornain5, GJ Fleuren2, JB Trimbos1 and AAW Peters1.
British Journal of Cancer (2012) 107, 772–777.. doi:10.1038/bjc.2012.334
www.bjcancer.com. Published online 31 July 2012 & 2012 Cancer Research UK.

 Global strategy to accelerate the elimination of cervical cancer as a public health

problem. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0
IGO.

 Human papillomavirus vaccines: WHO position paper (2022 update). 16

Reff : DECEMBER 2022, 97th YEAR. No 50, 2022, 97, 645–672. http://www.who.int/wer
.

 NCCN guidelines for parient. Cervical cancer. 2022

 WHO guidelines for screening and treatment of precancerous lesions for cervical
cancer prevention. © World Health Organization 2013.

 WHO guideline for screening and treatment of cervical pre-cancer lesions for
cervical cancer prevention, second edition. © World Health Organization 2021.

 WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions.
Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.